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Sample Assessments

Browse through the curated selection of our completed assessments to get a sense of the quality and depth of our work. Whether you need guidance, inspiration, or just want to evaluate our work, this page is your go-to resource.

WGU NURS5205 D028 Advanced Health Assessment for Patients and Populations - Evidence-Based Practices to Prevent Hospital Readmissions

Hospital readmissions can be significantly reduced through the application of evidence-based interventions. These practices begin during the initial care phase and continue well beyond hospital discharge, involving a multidisciplinary approach that considers the patient’s social determinants of health (SDOH), medical history, and willingness to adhere to care plans. The active participation of both the patient and their family is crucial, as they are key stakeholders in the process.

Patients play a central role in managing their health conditions, with nurses acting as vigilant supporters who assess, review, and provide ongoing education. Nurses are vital advocates, ensuring that patients remain engaged throughout the care planning process and that all educational materials provided are clear and actionable. This continuous involvement helps equip patients with the knowledge and confidence needed to adhere to their care plans, ultimately reducing the likelihood of readmissions.

The variability in readmission rates and interventions across healthcare organizations highlights the importance of personalized care. Research has demonstrated that understanding and addressing a patient’s specific challenges—such as financial constraints, limited support systems, transportation issues, and education levels—through a comprehensive and supportive approach can effectively lower the risk of early readmissions (Leppin et al., 2014). These social determinants of health must be integral to discharge planning to ensure success.

Case managers, often trained social workers or registered nurses, play a pivotal role in facilitating successful discharges. They act as patient advocates, collaborating with inpatient and outpatient teams, including surgeons and hospital staff, to address patient needs. This may involve arranging essential follow-up appointments or in-home care to bridge gaps in support.

Education is a shared responsibility among disciplines, including physical and occupational therapists, surgeons, nurses, and dieticians. It should be delivered in a manner that is clear and concise, complemented by comprehensive discharge instructions containing contact information for follow-up questions. Short, focused educational sessions that include demonstrations and opportunities for questions help patients and their families better retain information. Understanding how to manage their diagnoses, particularly as they age, enables patients to take an active role in their healthcare, which is essential for improved outcomes.

References
Leppin, A.L., Gionfriddo, M.R., Kessler, M., Pablo Brito, J., Mair, F.S., Gallacher, K., Wang, Z., Erwin, P.J., Sylvester, T., Boehmer, K., Ting, H.H., Murad, M.H., Shippee, N.D., & Montori, V.M. (2014). Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med. 174(7), 1095-1107. https://dx.doi.org/10.1001%2Fjamainternmed.2014.1608

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